Plateletpheresis

A 250 ml bag of newly collected platelets.

Plateletpheresis (also called thrombapheresis or thrombocytapheresis) is the process

of collecting platelets, the components of blood that are involved in hemostasis (blood
clotting). It can be a life-saving procedure in preventing or treating serious complications
from bleeding and hemorrhage in patients who have disorders manifesting as
thrombocytopenia (low platelet count) or platelet dysfunction. This process may also be
used therapeutically to treat disorders resulting in extraordinarily high platelet counts
such as Essential Thrombocytosis.

Indications for transfusion

Platelet transfusions are traditionally given to those undergoing chemotherapy for
leukemia, those with aplastic anemia, AIDS, hypersplenism, ITP, sepsis, DIC, or
surgeries such as cardiopulmonary bypass. Platelet transfusions should be avoided in
those with TTP-HUS because it can worsen neurologic symptoms and acute renal failure,
presumably due to creation of new thrombi as the platelets are consumed. It should also
be avoided in those with heparin-induced thrombocytopenia (HIT).

Thrombocytopenia due to underproduction. Patients in this category falls under those

undergoing chemotherapy, those with myelophthisic marrow, AIDS, or with aplastic
anemia. If indicated, transfusions (one plateletphresis concentrate) should be given until
recovery of platelet function, generally approximately twice weekly. Surgical bleeding
due solely to thrombocytopenia occurs when platelets < 50,000/uL while spontaneous
bleeding occurs when platelets < 10,000/uL. Thrombocytopenic patients can develop
"dry" bleeding, that is, petechiae and ecchymoses only. They will not suffer fatal
hemorrhagic events unless they first have extensive mucosal bleeding, or "wet" bleeding.
Therefore, in those with no bleeding or only "dry" bleeding, the threshold for transfusion
should be between 5,000 to 10,000/uL. A more conservative threshold of 20,000/uL
should be used in those with a fever or other risk factors for bleeding. Those with active
bleeding or prior to surgery should have a threshold of 50,000/uL. An unconfirmed, but
helpful, way to determine whether a patient is recovering from chemotherapy-induced
thrombocytopenia is to measure "reticulated" platelets, or young RNA-containing
platelets, which signifies that the patient is starting to make new platelets.

Immune thrombocytopenia. Patients in this category include those with ITP or drug-
induced thrombocytopenia. Platelet transfusions are generally not recommended for this
group of patients because the underlying cause involves antibodies that destroy platelets,
therefore any newly transfused platelets will also be destroyed. More studies need to be
done.

Altered platelet functions. Disorders of platelet function can be congenital or acquired.

Most of these disorders are mild and may respond to therapy with desmopressin
(dDAVP). Transfusion is not necessarily required. However, with some more severe
disorders such as Glanzmann thrombasthenia, transfusions with large amount of platelets
may be needed. The number of transfusions may be reduced if these patients are given
recombinant human factor VIIa since the underlying cause are antibodies to platelet
glycoproteins IIb/IIIa.

Cardiopulmonary bypass surgery. This surgery can result in destruction of a large

proportion of the patient's platelets and may render the remaining viable platelets to be
dysfunctional. The indications for transfusion in such patients is controversial. General
guidelines recommends not transfusing patients prophylactically but only when they are
bleeding excessively, while also giving desmopressin.

Drug-induced platelet dysfunction. The most common of these is aspirin, and its
similar drug class, the NSAIDs. Other antiplatelet drugs are commonly prescribed for
patients with acute coronary syndromes such as clopidogrel and ticlopidine. When
surgery is undertaken following the administration of these drugs, bleeding can be
serious. Transfusion under these circumstances is not clear-cut and one has to use clinical
judgment in these cases.

Expected platelet increase after transfusion

Platelet count increase as well as platelet survival after transfusion is related to the dose
of platelets infused and to the patient's body surface area (BSA). Usually these values are
less than what would be expected.

• Corrected platelet count increment (CCI) = platelet increment at one hr x BSA

(m2) / # platelets infused x 1011
• Expected platelet increase (per μL) = platelets infused x CCI / BSA (m2)

The theoretical value of the CCI is 20,000/μL but clinically, the value is more close to
10,000/μL. If the CCI is less than 5,000/μL, patients are said to have "refractoriness" to
platelet transfusion.
Platelet collection
The separation of individual blood components is done with a specialized centrifuge (see
apheresis). The earliest manual forms of plateletpheresis are done by the separation of
platelets from multiple bags of whole blood collected from donors or blood sellers. Since
each blood bag (usually 250 ml or 500 ml) contains a relatively small number of platelets,
it can take as many as a dozen blood bags (usually from 5 to 10 bags, depending on the
size of the blood bags and each donor's platelet count) to accumulate a single unit of
platelets (enough for one patient). This greatly increases the risks of the transfusion. Each
unit of platelets separated from donated whole blood is called a "platelet concentrate".

Modern automatic plateletpheresis allows the blood donor to give a portion of his
platelets, while keeping his or her red blood cell and at least a portion of blood plasma.
Therefore, no more than three units of platelets are generally harvested in any one sitting
from a donor.

Because platelets have a life-span of just 5 days, more platelet donors are always needed.

Even though red blood cells can also be collected in the process, most blood donation
organizations do not do so because it takes much longer for the human body to replenish
their loss. If the donor donates both red blood cells and platelets, it takes months, rather
than days or weeks, before they are allowed to donate again (the guidelines regarding
blood donation intervals are country-specific).

In most cases, blood plasma is returned to the donor as well. However, in locations that
have plasma processing facilities, a part of the donor's plasma can also be collected in a
separate blood bag (see plasmapheresis).

Leukoreduction

Due to their higher relative density, white blood cells are collected as an unwanted
component with the platelets. Since it takes up to 3 liters of whole blood (the amount of a
dozen of blood bags) to generate a dose of platelets, white blood cells from one or several
donors will also be collected along with the platelets. A 70 kg (154 lb) man has only
about 6 liters of blood. If all of the incidentally collected white blood cells are transfused
with the platelets, substantial rejection problems can occur. Therefore, it is standard
practice to filter out white blood cells before transfusion by the process of
leukoreduction.

Early platelet transfusions used a filter to remove white blood cells at the time of
transfusion. It takes a trained person about 10 minutes to assemble the equipment, and
this is not the safest or most efficient means of filtration because living white blood cells
can release cytokines during storage and dead white blood cells can break up into smaller
fragments that can still stimulate a dangerous response from the immune system. In
addition, simple filtration can lead to increased risks of infection and loss of valuable
platelets. Newer, more advanced plateletpheresis machines can filter white blood cells
during separation.

For example, with marginally acceptable whole blood (white blood cells: < 10,000/mm³;
platelets: > 150,000/mm³), a dose (3×1011) of platelets comes with about 2×1010 white
blood cells. This can seriously damage the patient's health. A dose of single-donor
platelets prepared using latest filters can contain as little as 5×104 white blood cells.

Apheresis

There are two types of manual platelet apheresis. Platelet-rich plasma (PRP) is widely
used in North America and Buffy coat (BC) is more widely used in Europe.

Platelets are the clotting factor of your blood, and when donated, frequently go to cancer
patients, because due to chemotherapy many cancer patients are unable to generate
enough platelets of their own.

The basic principles of automatic platelet apheresis are the same as in the manual
procedure, but the whole procedure is performed by a computer-controlled machine.
Since the donor's blood is processed in a sterile single-use centrifuge, the unwanted
components can be returned to the donor safely. This allows the apheresis machine to
repeat the draw-centrifuge-return cycle to obtain more platelets. The bulk of the machine
and the length of the donation process means most platelet donations are done in blood
centers instead of moblie blood drives.

A platelet donor must usually weigh at least 50 kg (110 lb) and have a platelet count of at
least 150×105/mm³. Each country has its own rules to protect the safety of both donor and
recipient. One unit has about 3×1011 platelets. Therefore, it takes 2 liters of blood having
a platelet count of 150×105/mm³ to produce one unit of platelets. Some regular donors
have higher platelet counts (over 300×105/mm³); for those donors, it only takes about one
liter of their blood to produce a unit. Since the machine used to perform the procedure
uses suction to pull blood out of your body, some people that can give whole blood may
have veins too small to use for platelet donation. Your blood center can evaluate you prior
to donation.

Blood accounts for about 8% of body weight, giving a 50 kg donor about four liters of
blood. No more than 50% of platelets are ever extracted in one sitting, and they can be
replenished by the body in about three days.

Most newer apheresis machines can separate a dose of platelets in about 60 to 120
minutes depending on the donor's health condition.

Platelet donation
After a mini-physical, the donor is taken into the donation room and sits in a chair next to
the machine. The tech cleans one arm with iodine, or other disinfectant, and inserts the
needle. The process takes about one to two hours while blood is pulled into the machine,
spun around, and replaced along with an anticoagulant, usually Sodium Citrate. The
donor may have the option of donating a unit of plasma with the platelets, if he chooses.
The donor's blood is pulled into the machine and returned to the donor usually about 6-8
times, accounting for the length of the donation.

Occasional side effects of the donation of platelets include tingling, chills, slight nausea,
bruising, fatigue, and dizziness. Frequently while donating your lips may begin to tingle;
the techs usually keep a supply of calcium antacid tablets close by because the
anticoagulant works by binding to the calcium in your blood. Since calcium is used in the
operation of the nervous system, nerve-ending-dense areas (like your lips) are suscepible
to the tingling. Usually chewing a handful of antacid tablets will raise calcium levels and
relieve the tingling. Bruising may also occur. Fatigue and dizziness are generally not as
common after donating platelets as it is after donating blood because you get your red
blood cells back.

Aside from the procedure, donating platelets is different from donating blood in a few
ways.

First, you cannot take aspirin for anywhere from 36 to 72 hours prior to your donation.
(Guidelines vary by blood center.) The reason for this is that aspirin is a potent drug that
prevents platelets from working. Some blood centers also prohibit the taking of ANY
NSAID (non-steroidal-anti-inflammatory-drug) for 36-hours prior. Different centers have
different policies, so contact the center before donating.

Second, you are generally allowed to donate platelets anywhere from every 3-28 days.
This is a stark contrast to whole-blood donation, which has an eight-week waiting period
between donations. Along those lines, since platelet donation does temporarily remove
whole-blood from your body, you may have to wait eight weeks after a whole blood
donation to donate platelets.

Third, you may be required to have some additional tests done before becoming a donor
for the first time. These tests are used to establish your platelet count, and also possibly to
determine your compatibility with particular recipients through an HLA (Human
Leukocyte Antigen) test. The tests usually involve nothing more involved than the
drawing of several tubes of blood.

Haemonetics

The Haemonetics machine draws a large amount of blood in each cycle.

Usually 5-7 cycles per donation (approx. 10 min per cycle). You can donate up to two
platelet units during one donation (this is done with donors with a high count), and a unit
of plasma can also be donated, at the center's discretion.
Trima

The Trima Automated Blood Collection System can collect two doses within two hours.
The donor should have a platelet count of over 250×105/mm³. This unit also draws more
suction than the Haemonetics and lacks an automated arm cuff. This means it requires a
pretty fair-sized vein to support unless a portable blood pressure cuff is available.

The Trima collection system has incorporated a leukocyte reduction "cone" as part of the
disposable kit. Use of this device routinely produce platelet concentrates with White
Blood Cell counts of less than 1×106 per product.

However, the Trima draws and returns blood in very small amounts more frequently than
the Haemonetics, resulting in more than 100 cycles/unit (draw 40 sec, return 15 sec). This
generally results in a lower pressure drop during the cycle since less blood is out of your
body at any one time.

"Trima" can also perform the collection of platelets, plasma and red blood cells
simultaneously.

COBE Spectra

This older unit is still in use in some blood centers. While it can perform a single-needle
donation, the most common method with this machine is to draw with one needle, and
return with the other, continuously drawing the blood through a centrifuge (instead of
using cycles). For obvious reasons, the single needle Trima and Haemonetics machines
are more popular, while the COBE Spectra is being phased out.

[edit] Vein scarring

Repeated platelet donations at short intervals will cause the venipuncture site to scar.
While cosmetically it is virtually invisible, the scarring also occurs on the vein itself,
making it harder to insert a needle on future occasions. Anecdotal reports have said that
rubbing Vitamin E oil (or the insides of a Vitamin E capsule) on the venipuncture site
may reduce scarring.[citation needed]

It may be necessary to warn anybody outside of the blood center that needs to draw blood
from that site that your vein may be somewhat tougher than normal. Failure to do so may
result in the tech thinking they have missed the vein, not realizing that the vein simply
takes a little more pressure to stick.[citation needed]